The use of biologics such as platelet-rich plasma (PRP), mesenchymal stem cells, or growth factors in the orthopaedic office setting is becoming more common, fueled, in part, by a growing body of research and increasing market demand for alternative methods of nonsurgical management of soft-tissue and musculoskeletal conditions.

The use of biologics has been facilitated by advances in imaging technology such as musculoskeletal ultrasound. In addition, platelet processing centrifuges are becoming more affordable. Practical strategies for office use depend on the surgeon’s patient flow and practice patterns.

Although additional research is required to optimize the following recommendations, they may be helpful as limited guidelines for current office use.

Equipment and methodology considerations
Several different manufacturers offer centrifuges, with different levels of automation and platelet concentration techniques. All provide closed systems with “single-use kits,” which ultimately result in additional cost considerations.

Duration of centrifuge processing is usually 15 to 20 minutes. A sterile barrier may be necessary, depending on automation and centrifuge processing protocols.

Current recommendations are that the platelet concentration be raised to 4 to 6 times above the baseline concentration. Further research is required to optimize recommendations.

Bovine thrombin and/or calcium may be used as an activation agent, depending on procedure.

Musculoskeletal ultrasound may be used to guide needle placement.

Administrative considerations
The three most significant administration considerations are time commitment, insurance coverage, and informed consent.

Some surgeons incorporate image-guided injections into their regular office practice, while others set specific hours for such procedures.

Nomenclature and recognized research vary among insurance carriers. Few third-party carriers are currently reimbursing for PRP injections. Recently, the American Medical Association introduced a new category III (new technology) Current Procedural Terminology (CPT) code for the performance of PRP injection procedures. The new code includes the harvesting of the blood, spinning of the blood, and injection of the remaining plasma and should be used only when PRP is performed during a completely separate patient encounter from a surgical procedure.

The new code does not have an assigned Medicare value and is priced by regional carriers. Physicians will need to estimate the work involved in providing the service. At present, PRP injections should be considered a direct cost to the patient.

As for any typical medical procedure, the PRP injection process should be thoroughly discussed with the patient, who should sign a consent form before the procedure.

Pre-injection guidelines
The patient should be aware of and compliant with the following guidelines:

• No corticosteroids for 2 to 3 weeks before the procedure.
• Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs). Although no formal recommendations have been made in this area, our practice suggests that the patient discontinue taking NSAIDs a minimum of 1 week before the procedure.
• No anticoagulation use 5 days before the procedure.
• Increase fluid intake in the 24 hours preceding the procedure.
• Anti-anxiety medication may be required for certain patients.

Contraindications
The following conditions should be considered as contraindications for PRP injection: hematologic blood dyscrasias with platelet dysfunction; septicemia or fever; cutaneous infections in the area to be injected; anemia (hemoglobin less than 10 deciliters; malignancy, particularly with hematologic or bony involvement; allergy to bovine products if bovine thrombus is to be used.

Procedure
The procedure is simple. With sterile technique, obtain appropriate amount of venous blood and transfer it to the centrifuge. After processing is completed, extract the PRP from the centrifuge according to the manufacturer’s instructions.

Cleanse the patient’s skin around the injection site; if desired, use towels or drapes to create an aseptic field. Administer a local anesthetic if necessary. With real-time image guidance (computed tomography, fluoroscopy, or ultrasound) and sterile technique, inject the PRP into the appropriate area; apply dressing or bandage to protect needle entry site.

Complications
Reported adverse effects are not different from those of normal venipuncture or injections at the same body locations. PRP injections, however, are frequently more painful than other injections due to the viscosity of the solution.

Santos F. Martinez, MD, is affiliated with the Campbell Clinic. He can be reached at sfmartinez@campbellclinic.com

Editor’s note: Although neither the AAOS nor AAOS Now advocate the use of platelet-rich plasma, these guidelines may be helpful to those who are considering adding this therapy to their treatment armamentarium.